A 46-year-old woman comes to the office due to tingling, numbness, and weakness of the left upper extremity. The patient experienced left shoulder and subscapular pain during a vacation 1 month ago, which she attributed to sleeping on a new bed. She saw a chiropractor upon returning and has taken ibuprofen as needed. Over the past 3 weeks, she has also experienced tingling and numbness in her left hand and has had mild left arm weakness. The patient spends prolonged time answering the phone at work and has noticed the symptoms worsen after cradling the phone between the head and the left shoulder. She has a history of hypothyroidism and takes levothyroxine. Vital signs are within normal limits. Physical examination shows loss of pinprick sensation in the left thumb and index finger. There is mild weakness of the elbow flexion and biceps reflex is decreased on the left side. Which of the following is the most likely cause of this patient's symptoms?

Question

A 46-year-old woman comes to the office due to tingling, numbness, and weakness of the left upper extremity.  The patient experienced left shoulder and subscapular pain during a vacation 1 month ago, which she attributed to sleeping on a new bed.  She saw a chiropractor upon returning and has taken ibuprofen as needed.  Over the past 3 weeks, she has also experienced tingling and numbness in her left hand and has had mild left arm weakness.  The patient spends prolonged time answering the phone at work and has noticed the symptoms worsen after cradling the phone between the head and the left shoulder.  She has a history of hypothyroidism and takes levothyroxine.  Vital signs are within normal limits.  Physical examination shows loss of pinprick sensation in the left thumb and index finger.  There is mild weakness of the elbow flexion and biceps reflex is decreased on the left side.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d82b_f952_bc81_bfe71bd35302_MD0003_00 This patient has sensorimotor deficits affecting a discrete portion of the left arm associated with a diminished biceps reflex, suggesting a lesion of the peripheral nervous system. The deficits are not isolated to the distribution of a single peripheral nerve (eg, median, ulnar), but rather follow the dermatomal (ie, thumb and index finger) and myotomal (ie, elbow flexion) pattern of C6, consistent with a cervical radiculopathy. Cervical radiculopathies occur due to compression of a spinal nerve root; in addition to sensorimotor deficits that follow the pattern of the affected nerve root, most patients also report neck or shoulder/arm pain. Lateral flexion and rotation of the neck (as occurs when cradling a phone between the head and shoulder) narrows the ipsilateral neural foramina, worsening compression of the nerve root. Worsening limb pain and paresthesia in response to lateral neck flexion is relatively specific for cervical radiculopathy, although worsening pain in the neck with this maneuver is not. In contrast, shoulder abduction reduces tension on the impinged nerve root, and improvement of radicular symptoms when the hand is placed on the top of the head (ie, shoulder abduction relief test) can be both diagnostic and therapeutic for short-term pain relief. (Choice A) Although median nerve injury can result in sensory deficits of the thumb and index finger, it would not cause weakness of elbow flexion or a diminished biceps. Neck pain is unexpected. (Choice B) Peripheral nerve demyelination (eg, chronic inflammatory demyelinating polyneuropathy) typically results in symmetric sensorimotor deficits, rather than deficits confined to a portion of one limb. (Choice C) Spinal cord demyelination (eg, transverse myelitis) typically results in deficits affecting all areas below the level of injury. Symptoms would not be limited to a single dermatome. Furthermore, it would likely result in upper motor neuron signs (eg, hyperreflexia), rather than hyporeflexia. (Choice E) Ulnar nerve compression would result in sensory deficits of the ring and little fingers with finger weakness (ie, decreased grip strength). It would not cause numbness of the thumb or index finger or result in weakness of elbow flexion or a diminished biceps reflex. Educational objective: Cervical radiculopathies occur due to spinal nerve root compression and typically causes neck pain associated upper extremity sensorimotor deficits that follow a dermatomal/myotomal pattern. Lateral flexion and rotation of the neck worsens compression of the nerve root, worsening pain and/or paresthesia.

A 46-Year-Old Woman Comes to the Office Due to Tingling